Advanced Endoscopy Fellows Program | September 2022-Bhatt

Bhatt_Eso Adenocarcinma Case

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This document discusses a case of esophageal adenocarcinoma in a 79-year-old male who was incidentally diagnosed during an evaluation for a persistent cough. The patient has a history of coronary artery disease, chronic obstructive pulmonary disease, and aortic stenosis. The cancer is staged as T1bN1, and the question of whether endoscopic resection is appropriate is raised.<br /><br />The principles of endoscopic resection of early esophageal adenocarcinoma are explored, highlighting the differences between endoscopic and surgical resection, such as the absence of lymph node dissection. Endoscopic resection should only be considered in lesions with a low risk of lymph node metastasis or when weighed against the risks associated with surgery.<br /><br />The risks of esophagectomy, including mortality and morbidity, are presented. The documented mortality rates range from 1.2% at Cleveland Clinic to 4.2% nationally. Overall morbidity rates are also discussed, with categories including respiratory failure, leaks, and sepsis.<br /><br />Factors that can help determine the risk of lymph node metastasis, such as depth of invasion, tumor differentiation, and lymphovascular invasion, are examined. The accuracy of pre-operative methods such as PET scans and endoscopic ultrasound (EUS) in assessing depth of invasion is questioned, as a significant number of T1b tumors were classified as T1a pre-resection.<br /><br />The importance of staging endoscopic resection based on available information, including depth of invasion, lymphovascular invasion, and tumor differentiation, is emphasized. The case mentions a benign lymph node on fine-needle aspiration (FNA), and the pathology of the resected tumor is reported as T1a with a negative margin and poorly differentiated pathology, as well as the presence of lymphovascular invasion.<br /><br />Future steps for this case are discussed, including adjuvant radiation therapy and the need for radiofrequency ablation (RFA) of any residual Barrett's esophagus. The patient did not complete RFA ablation initially, and three years later, developed metachronous cancer requiring a second endoscopic resection.<br /><br />In conclusion, this document presents a case of esophageal adenocarcinoma and discusses the role of endoscopic resection, the risks associated with esophagectomy, and the importance of accurate pre-operative staging. It highlights the necessity of completing treatment for Barrett's esophagus to prevent metachronous cancer.

Keywords

esophageal adenocarcinoma

endoscopic resection

lymph node metastasis

esophagectomy risks

depth of invasion

tumor differentiation

lymphovascular invasion

PET scans

fine-needle aspiration

Barrett's esophagus